Impact of Legislation on Opioid Prescribing following Hysterectomy and Hysteroscopy in Arizona and Florida

2021 ◽  
pp. 1-9
Author(s):  
Aakriti R. Carrubba ◽  
Amy E. Glasgow ◽  
Elizabeth B. Habermann ◽  
Amanda P. Stanton ◽  
Megan N. Wasson ◽  
...  
Keyword(s):  
Statistical Analysis ◽  
Cohort Analysis ◽  
Oral Morphine ◽  
Interrupted Time Series ◽  
Interrupted Time Series Analysis ◽  
Opioid Use ◽  
Prescribing Practices ◽  
Opioid Prescribing ◽  
Before And After ◽  
Legislative Changes

<b><i>Objectives:</i></b> This study aimed to determine the oral morphine equivalents (OMEs) prescribed and refill rates following hysterectomy and hysteroscopy in the setting of opioid prescribing practice changes in 2 states. <b><i>Design:</i></b> This is a retrospective cohort analysis consisting of 2,916 patients undergoing hysterectomy or hysteroscopy between July 2016 and September 2019 at 2 affiliated academic hospitals in states that underwent legislative changes in opioid prescribing in 2018. <b><i>Methods:</i></b> Participants were identified using the Current Procedural Terminology procedure codes in Arizona and Florida. Hysterectomy was chosen as the most invasive gynecologic procedure, while hysteroscopy was chosen as the least invasive. Medical records were abstracted to find opioid prescriptions from 90 days before surgery to 30 days after discharge. Patients with opioid use between 90 and 7 days before surgery were excluded. Prescriptions were converted to OMEs and were calculated per quarter year. Statistical analysis included Wilcoxon rank sum <i>t</i> tests for OMEs and χ<sup>2</sup> <i>t</i> tests for refill rates. Interrupted time-series analysis was used to determine significant change in OMEs before and after legislative change. Statistical analysis was performed using SAS version 9.4 (SAS Institute, Cary, NC, USA). <b><i>Results:</i></b> In Arizona, 1,067 hysterectomies were performed; 459 (43%) vaginal, 561 (52.6%) laparoscopic/robotic, and 47 (4.4%) abdominal. There were 530 hysteroscopies. Overall median OMEs decreased from 225 prior to July 2018 to 75 after July 2018 (<i>p</i> &#x3c; 0.0001). The opioid refill rate remained unchanged at 7.4% (<i>p</i> = 0.966). In Florida, there were 769 hysterectomies; 241 (31.3%) vaginal, 476 (61.9%) laparoscopic/robotic, and 52 (6.8%) abdominal. There were 549 hysteroscopies. Overall median OMEs decreased from 150 prior to July 2018 to 0 after July 2018 (<i>p</i> &#x3c; 0.0001). The opioid refill rate was similar (7.8% before July 2018 and 7.3% after July 2018; <i>p</i> = 0.739). <b><i>Limitations:</i></b> Limitations include involvement of a single hospital institution with a total of 10 fellowship-trained surgeons and biases inherent to retrospective study design. <b><i>Conclusions:</i></b> Legislative and provider-led changes coincided with decreases in opioid prescribing after 2018 in both states without increasing rates of refills and showed actual data reflected in the medical record. Gynecologists must actively participate in safe prescribing practices to decrease opioid dependence and misuse.

ED syphilis and gonorrhea/chlamydia cotesting practices before and after the implementation of an electronic health record-based alert

2021 ◽  
pp. emermed-2020-210331
Author(s):  
James S Ford ◽  
Tasleem Chechi ◽  
Michella Otmar ◽  
Melissa Baker ◽  
Sarah Waldman ◽  
...  
Keyword(s):  
Electronic Health Record ◽  
Underserved Populations ◽  
Cohort Analysis ◽  
Treponema Pallidum ◽  
Interrupted Time Series ◽  
Health Record ◽  
Interrupted Time Series Analysis ◽  
Syphilis Testing ◽  
Before And After ◽  
Electronic Health

BackgroundThe prevalence of syphilis is increasing in many countries, including the USA. The ED is often used by underserved populations, making it an important setting to test and treat patients who are not evaluated in outpatient clinical settings. We aimed to assess the utility of an ED-based syphilis and gonorrhoea/chlamydia cotesting protocol by comparing testing practices before and after its implementation.MethodsWe implemented an electronic health record (EHR) alert that prompted clinicians to order syphilis testing in patients undergoing gonorrhoea/chlamydia testing. We performed a retrospective cohort analysis that compared outcomes between the preimplementation period (January–November 2018) and the postimplementation period (January–November 2019). Patients were tested for Treponema pallidum antibody (TPA) using a multiplex flow immunoassay (MFI), and positive results were confirmed by rapid plasma reagin (RPR). The primary implementation outcome was the number of syphilis tests/month, and the primary clinical outcome was the number of syphilis diagnoses/month (defined as positive TPA MFI and RPR). We performed an interrupted time-series analysis to evaluate the effect of implementing the alert over time.ResultsFour-hundred and ninety-four and 1106 unique patients were tested for syphilis in the preimplementation and postimplementation periods, respectively. Syphilis testing increased by 55.6 tests/month (95% CI 45.9 to 65.3, p<0.001) following alert implementation. Patients tested in the postimplementation period who were tested using the alert were much younger (difference: 14 years (95% CI 12 to 15)) and were more likely to be female (difference: 15% (95% CI 8 to 21)) and African-American (difference: 11% (95% CI 5 to 17)) than patients tested by clinician-initiated testing. Presumptive syphilis diagnoses increased from 3.4 diagnoses/month to 7.9 diagnoses/month (difference, 4.5 (95% CI 2.2 to 6.9), p<0.001).ConclusionsOur study demonstrates that use of a targeted EHR alert testing protocol can increase syphilis testing and diagnosis and may reduce clinician bias in testing.

scholarly journals Effects of Rescheduling Hydrocodone on Opioid Prescribing in Ohio

Pain Medicine ◽  
2019 ◽  
Vol 21 (9) ◽  
pp. 1863-1870 ◽  
Author(s):  
Yingna Liu ◽  
Olesya Baker ◽  
Jeremiah D Schuur ◽  
Scott G Weiner
Keyword(s):  
Monitoring Program ◽  
Interrupted Time Series ◽  
Substitution Effect ◽  
The United States ◽  
Prescription Database ◽  
Interrupted Time Series Analysis ◽  
Opioid Prescribing ◽  
Level Change ◽  
Prescribing Trends ◽  
Before And After

Abstract Background We quantified opioid prescribing after the 2014 rescheduling of hydrocodone from schedule III to II in the United States using a state-wide prescription database and studied trends three years before and after the policy change, focusing on certain specialties. Methods We used Ohio’s state prescription drug monitoring program database, which includes all filled schedule II and III prescriptions regardless of payer or pharmacy, to conduct an interrupted time series analysis of the nine most prescribed opioids: hydrocodone, oxycodone, tramadol, codeine, and others. We analyzed hydrocodone prescribing trends for the physician specialties of internal medicine, anesthesiology, and emergency medicine. We evaluated trends 37 months before and after the rescheduling change. Results Rescheduling was associated with a hydrocodone level change of –26,358 (95% confidence interval [CI] = –36,700 to –16,016) prescriptions (–5.8%) and an additional decrease in prescriptions of –1,568 (95% CI = –2,296 to –839) per month (–0.8%). Codeine prescribing temporarily increased, at a level change of 6,304 (95% CI = 3,003 to 9,606) prescriptions (18.5%), indicating a substitution effect. Hydrocodone prescriptions by specialty were associated with a level change of –805 (95% CI = –1,280 to –330) prescriptions (–8.5%) for anesthesiologists and a level change of –14,619 (95% CI = –23,710 to –5,528) prescriptions (–10.2%) for internists. There was no effect on prescriptions by emergency physicians. Conclusions The 2014 federal rescheduling of hydrocodone was associated with declines in hydrocodone prescriptions in Ohio beyond what had already been occurring, and hydrocodone may have been briefly substituted with codeine. These results indicate that rescheduling did have a lasting effect but affected prescribing specialties variably.

Effect of a Standardized Electronic Medical Record Order Set on Opioid Prescribing after Tonsillectomy

2020 ◽  
Vol 163 (2) ◽  
pp. 216-220 ◽  
Author(s):  
Joshua D. Horton ◽  
Corinne Corrigan ◽  
Terral Patel ◽  
Caroline Schaffer ◽  
Robert A. Cina ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Pain Control ◽  
Retrospective Chart Review ◽  
Postoperative Hemorrhage ◽  
Opioid Use ◽  
Prescribing Practices ◽  
Opioid Prescribing ◽  
Before And After ◽  
Order Set

Objective Approximately 5% of children develop new persistent opioid use after tonsillectomy. Critical review of our prescribing practices revealed inconsistent and excessive opioid prescribing after this procedure in children. We sought to improve our practice by using a standardized electronic medical record (EMR)–based order set. Methods Retrospective chart review of outpatient tonsillectomy performed before and after institution of an EMR intervention with comparison of opioid and nonopioid analgesic (NOA) prescription characteristics as well as outcomes including hemorrhage and readmission. Results Analysis of 276 preorder set and 128 post–order set tonsillectomies revealed a significant increase in NOA utilization following initiation of the order set and a significant reduction in doses of opioid prescribed. Due to a change to a stronger opioid in the order set, morphine dose equivalents (MDEs) prescribed were not decreased in the post–order set cohort. Variability between prescriptions and providers was significantly decreased in the post–order set group in terms of doses and MDEs, and dangerously high outlier prescriptions were eliminated. No differences in pain control, postoperative hemorrhage, presentation to the emergency department, or readmission were identified. Discussion An EMR-based intervention improved the quality and safety of posttonsillectomy opioid prescribing at our institution. Moving forward, this order set provides a platform with which to titrate opioid prescriptions and NOA to optimal pain control and safety levels. Implications for Practice A standardized EMR-based order set can improve the quality of opioid prescribing after tonsillectomy.

scholarly journals Retrospective study of the effect of opioid prescribing guidelines on prescribing practices in pediatric orthopedic sports medicine patients having knee surgery: A single institution's experience

2021 ◽  
Vol 17 (4) ◽  
pp. 284-288
Author(s):  
Jeffrey G. Stepan, MD, MSc ◽  
Christine Goodbody, MD ◽  
Kanupriya Kumar, MD ◽  
Kathryn DelPizzo, MD ◽  
Peter Fabricant, MD, MPH ◽  
...  
Keyword(s):  
Sports Medicine ◽  
Pediatric Patients ◽  
Tertiary Care ◽  
Oral Morphine ◽  
Knee Surgery ◽  
Prescribing Practices ◽  
Opioid Prescription ◽  
Opioid Prescribing ◽  
Before And After ◽  
Pediatric Orthopedic

Objective: Guidelines for opioid prescription post-operatively exist; however, the majority of these are for adults. Nevertheless, opioid risks are present for pediatric patients also. This study investigates the effect of a single institution's guidelines on post-operative opioid prescribing for pediatric orthopedic patients undergoing knee surgery. We hypothesized that a standardized set of prescribing guidelines would result in a decrease in opioids prescribed at discharge home after these surgeries.Design: Retrospective observational.Setting: Urban, tertiary care, academic orthopedic hospital.Patients: Pediatric, sports knee surgery, 23-month period.Interventions: Guidelines were implemented institutionally for post-operative opioid prescribing practices. We reviewed all post-operative opioid prescriptions for pediatric patients undergoing sports knee surgery with two pediatric sports surgeons for the 11 months prior to the guidelines and 12 months afterwards, totaling 316 surgeries.Main outcome measure: Oral morphine equivalents (OMEs) prescribed on discharge from the hospital before and after implementation of guidelines. Results: There was a significant reduction in OMEs from 229 OMEs to 175 OMEs before and after opioid prescribing guidelines (p 0.001). This is a decrease in approximately seven 5 mg oxycodone tablets per patient.Conclusions: This study demonstrates that at our institution, with a pediatric patient population having sports knee surgery, prescribing guidelines reduced the number of opioids prescribed at discharge.

354 Trends in the Drug-Sparing Effects for Benzodiazepines and Prescription Opioids among Insomnia Patients on Suvorexant in the US

SLEEP ◽  
2021 ◽  
Vol 44 (Supplement_2) ◽  
pp. A141-A141
Author(s):  
Hrishikesh Kale ◽  
Rezaul Khandker ◽  
Ruchit Shah ◽  
Marc Botteman ◽  
Weilin Meng ◽  
...  
Keyword(s):  
Interrupted Time Series ◽  
Charlson Comorbidity Index Score ◽  
Prescription Opioid ◽  
Prescription Opioids ◽  
Opioid Use ◽  
Before And After ◽  
Prescription Opioid Use ◽  
Incident Cohort ◽  
Over Time ◽  
Post Period

Abstract Introduction Use of benzodiazepines to treat insomnia has been associated with serious side effects and abuse potential. Insomnia patients are at high risk of opioid abuse and better sleep patterns may help to reduce opioid use. This study examined the trend in the use of benzodiazepines and prescription opioids before and after initiation of suvorexant in insomnia patients. Methods The study analyzed 2015–2019, Optum Clinformatics Data Mart. Insomnia patients, identified using ICD-9/10 codes and prescribed suvorexant were included. The study included incident (newly diagnosed) and prevalent cohorts of insomnia patients. The proportion of patients on benzodiazepines or prescription opioids were calculated for 12 monthly intervals before (pre-period) and after initiation of suvorexant (post-period). Interrupted time series (ITS) analysis was conducted to assess trends for use of benzodiazepine or prescription opioids over time. Results A total of 5,939 patients from the incident insomnia cohort and 18,920 from the prevalent cohort were included. For the incident cohort, mean age was 64.47 (SD: 15.48), 63% were females, 71% had Medicare Advantage coverage, 59% had Charlson comorbidity index score (CCI) ≥ 1, 27% had an anxiety disorder and 16% had substance abuse disorder. Prevalent insomnia cohort was similar but had higher CCI. Results from ITS suggested that at the beginning of the pre-period, 28% of incident insomnia patients used either opioids or benzodiazepines with the rate of use in the pre-period increasing by 0.11% per month. In the post-period, the rate of use decreased by 0.33% per month. About 26% patients used benzodiazepines or opioids at 12-month after suvorexant initiation. In the absence of suvorexant, this proportion would have been 31%. Similar findings were observed for the prevalent insomnia cohort. A larger decrease was observed for opioid use than benzodiazepines. Conclusion The rate of benzodiazepines or prescription opioid use decreased over time after the initiation of suvorexant. Suvorexant has the potential to reduce the use of opioids and benzodiazepines among insomnia patients. Further research is needed to confirm these findings. Support (if any) This study was sponsored by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA.

Effect of pharmacist-led task force to reduce opioid prescribing in the emergency department

2019 ◽  
Vol 76 (22) ◽  
pp. 1853-1861
Author(s):  
Nicole M Acquisto ◽  
Rachel F Schult ◽  
Sandra Sarnoski-Roberts ◽  
Jaclyn Wilmarth ◽  
Courtney M C Jones ◽  
...  
Keyword(s):  
Emergency Department ◽  
Task Force ◽  
Care Center ◽  
Linear Regression Analysis ◽  
Tertiary Care ◽  
Interrupted Time Series Analysis ◽  
Opioid Use ◽  
Entire Study ◽  
Opioid Prescribing ◽  
Reduction Program

Abstract Purpose Results of a study to determine the effect of a pharmacist-led opioid task force on emergency department (ED) opioid use and discharge prescriptions are presented. Methods An observational evaluation was conducted at a large tertiary care center (ED volume of 115,000 visits per year) to evaluate selected opioid use outcomes before and after implementation of an ED opioid reduction program by interdisciplinary task force of pharmacists, physicians, and nurses. Volumes of ED opioid orders and discharge prescriptions were evaluated over the entire 25-month study period and during designated 1-month preimplementation and postimplementation periods (January 2017 and January 2018). Opioid order trends were evaluated using linear regression analysis and further investigated with an interrupted time series analysis to determine the immediate and sustained effects of the program. Results From January 2017 to January 2018, ED opioid orders were reduced by 63.5% and discharge prescriptions by 55.8% from preimplementation levels: from 246.8 to 90.1 orders and from 85.3 to 37.7 prescriptions per 1,000 patient visits, respectively. Over the entire study period, there were significant decreases in both opioid orders (β, –78.4; 95% confidence interval [CI], –88.0 to –68.9; R2, 0.93; p < 0.0001) and ED discharge prescriptions (β, –24.4; 95% CI, –27.9 to –20.9; R2, 0.90; p < 0.001). The efforts of the task force had an immediate effect on opioid prescribing practices; results for effect sustainability were mixed. Conclusion A clinical pharmacist–led opioid reduction program in the ED was demonstrated to have positive results, with a more than 50% reduction in both ED opioid orders and discharge prescriptions.

scholarly journals Digital cognitive behavioural therapy for insomnia and primary care costs in England: an interrupted time series analysis

BJGP Open ◽  
2021 ◽  
pp. BJGPO.2021.0146
Author(s):  
Chris Sampson ◽  
Eleanor Bell ◽  
Amanda Cole ◽  
Christopher B Miller ◽  
Tracey Marriott ◽  
...  
Keyword(s):  
Primary Care ◽  
Time Series ◽  
Cognitive Behavioural Therapy ◽  
Interrupted Time Series ◽  
Behavioural Therapy ◽  
Interrupted Time Series Analysis ◽  
Cognitive Behavioural ◽  
Before And After ◽  
Quasi Experimental ◽  
Care Costs

BackgroundSleepio is an automated digital programme that delivers cognitive behavioural therapy for insomnia (dCBT-I). Sleepio has been proven effective in improving sleep difficulties. However, evidence for the possible impact of Sleepio use on health care costs in the United Kingdom has not previously been developed.AimWe sought to identify the effect of a population-wide rollout of Sleepio in terms of primary care costs in the National Health Service (NHS) in England.Design & settingThe study was conducted in the Thames Valley region of England, where access to Sleepio was made freely available to all residents between October 2018 and January 2020. The study relies on a quasi-experimental design, using an interrupted time series to compare the trend in primary care costs before and after the rollout of Sleepio.MethodWe use primary care data for people with relevant characteristics from nine general practices in Buckinghamshire. Primary care costs include general practice contacts and prescriptions. Segmented regression analysis was used to estimate primary and secondary outcomes.ResultsFor the 10,704 patients included in our sample, the total saving over the 65-week follow-up period was £71,027. This corresponds to £6.64 per person in our sample or around £70.44 per Sleepio user. Secondary analyses suggest that savings may be driven primarily by reductions in prescribing.ConclusionSleepio rollout reduced primary care costs. National adoption of Sleepio may reduce primary care costs by £20 million in the first year. The expected impact on primary care costs in any particular setting will depend on the uptake of Sleepio.

scholarly journals P113: Examining emergency physicians’ self-reported opioid prescribing practices for the treatment of acute pain: A Newfoundland perspective

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S105-S106
Author(s):  
P. Doran ◽  
G. Sheppard ◽  
B. Metcalfe
Keyword(s):  
Emergency Department ◽  
Acute Pain ◽  
Oral Morphine ◽  
Prescribing Patterns ◽  
Evidence Based ◽  
Emergency Physicians ◽  
Prescribing Practices ◽  
Opioid Prescribing ◽  
Ensure Patient Safety ◽  
Evidence Based Guidelines

Introduction: Canadians are the second largest consumers of prescription opioids per capita in the world. Emergency physicians tend to prescribe stronger and larger quantities of opioids, while family physicians write the most opioid prescriptions overall. These practices have been shown to precipitate future dependence, toxicity and the need for hospitalization. Despite this emerging evidence, there is a paucity of research on emergency physicians’ opioid prescribing practices in Canada. The objectives of this study were to describe our local emergency physicians’ opioid prescribing patterns both in the emergency department and upon discharge, and to explore factors that impact their prescribing decisions. Methods: Emergency physicians from two urban, adult emergency departments in St. John's, Newfoundland were anonymously surveyed using a web-based survey tool. All 42 physicians were invited to participate via email during the six-week study period and reminders were sent at weeks two and four. Results: A total of 21 participants responded to the survey. Over half of respondents (57.14%) reported that they “often” prescribe opioids for the treatment of acute pain in the emergency department, and an equal number of respondents reported doing so “sometimes” at discharge. Eighty-five percent of respondents reported most commonly prescribing intravenous morphine for acute pain in the emergency department, and over thirty-five percent reported most commonly prescribing oral morphine upon discharge. Patient age and risk of misuse were the most frequently cited factors that influenced respondents’ prescribing decisions. Only 4 of the 22 respondents reported using evidence-based guidelines to tailor their opioid prescribing practices, while an overwhelming majority (80.95%) believe there is a need for evidence-based opioid prescribing guidelines for the treatment of acute pain. Sixty percent of respondents completed additional training in safe opioid prescribing, yet less than half of respondents (42.86%) felt they could help to mitigate the opioid crisis by prescribing fewer opioids in the emergency department. Conclusion: Emergency physicians frequently prescribe opioids for the treatment of acute pain and new evidence suggests that this practice can lead to significant morbidity. While further research is needed to better understand emergency physicians’ opioid prescribing practices, our findings support the need for evidence-based guidelines for the treatment of acute pain to ensure patient safety.

scholarly journals The impact of implementing the 2016 WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience on perinatal deaths: an interrupted time-series analysis in Mpumalanga province, South Africa

2020 ◽  
Vol 5 (12) ◽  
pp. e002965
Author(s):  
Tina Lavin ◽  
Robert Clive Pattinson ◽  
Erin Kelty ◽  
Yogan Pillay ◽  
David Brian Preen
Keyword(s):  
Time Series ◽  
Time Series Analysis ◽  
Perinatal Mortality ◽  
Interrupted Time Series ◽  
Interrupted Time Series Analysis ◽  
Neonatal Deaths ◽  
Series Analysis ◽  
Before And After ◽  
Implementation Period ◽  
Early Neonatal Deaths

ObjectivesTo investigate if the implementation of the 2016 WHO Recommendations for a Positive Pregnancy Experience reduced perinatal mortality in a South African province. The recommendations were implemented which included increasing the number of contacts and also the content of the contacts.MethodsRetrospective interrupted time-series analysis was conducted for all women accessing a minimum of one antenatal care contact from April 2014 to September 2019 in Mpumalanga province, South Africa. Retrospective interrupted time-series analysis of province level perinatal mortality and birth data comparing the pre-implementation period (April 2014–March 2017) and post-implementation period (April 2018–September 2019). The main outcome measure was unadjusted prevalence ratio (PR) for perinatal deaths before and after implementation; interrupted time-series analyses for trends in perinatal mortality before and after implementation; stillbirth risk by gestational age; primary cause of deaths (and maternal condition) before and after implementation.ResultsOverall, there was a 5.8% absolute decrease in stillbirths after implementation of the recommendations, however this was not statistically significant (PR 0.95, 95% CI 0.90% to 1.05%; p=0.073). Fresh stillbirths decreased by 16.6% (PR 0.86, 95% CI 0.77% to 0.95%; p=0.003) while macerated stillbirths (p=0.899) and early neonatal deaths remained unchanged (p=0.499). When stratified by weight fresh stillbirths >2500 g decreased by 17.2% (PR 0.81, 95% CI 0.70% to 0.94%; p=0.007) and early neonatal deaths decreased by 12.8% (PR 0.88, 95% CI 0.77% to 0.99%; p=0.041). The interrupted time-series analysis confirmed a trend for decreasing stillbirths at 0.09/1000 births per month (−0.09, 95% CI −1.18 to 0.01; p=0.059), early neonatal deaths (−0.09, 95% CI −0.14 to 0.04; p=<0.001) and perinatal mortality (−1.18, 95% CI −0.27 to −0.09; p<0.001) in the post-implementation period. A decrease in stillbirths, early neonatal deaths or perinatal mortality was not observed in the pre-implementation period. During the period when additional antenatal care contacts were implemented (34–38 weeks), there was a decrease in stillbirths of 18.4% (risk ratio (RR) 0.82, 95% CI 0.73% to 0.91%, p=0.0003). In hypertensive disorders of pregnancy, the risk of stillbirth decreased in the post-period by 15.1% (RR 0.85; 95% CI 0.76% to 0.94%; p=0.002).ConclusionThe implementation of the 2016 WHO Recommendations for a Positive Pregnancy Experience may be an effective public health strategy to reduce stillbirths in South African provinces.

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